Apoplexy or Hemorrhage?

Apoplexy and hemorrhage are two conditions which can complicate PitNETs and which are frequently confused. Apoplexy is a severe complication which manifests itself by the sudden onset of headaches simulating a subarachnoid hemorrhage, a unilateral oculomotor nerve palsy, and an intense fatigue. Initially, MRI displays a mixture of T1 hyperintensities and T2W hypointensities. Presence of a fluid-fluid level in the initial imaging study eliminates the diagnosis of apoplexy. Nevertheless, T1W hyperintensity is frequently absent in the first two days. Diffusion-weighted imaging is consistent with restricted diffusion. Reactional thickening of the sphenoid sinus mucosa is very sensitive. Evolution is usually favorable without the need of surgery. Hemorrhage within a pituitary adenoma is usually detected on MRI without clinical manifestations. The pattern is of a cystic pituitary mass. A fluid-fluid level is characteristic, with typically a posterior dark component shown on sagittal T2WI and a T1-T2 hyperintense anterior component.